CurrentOklahoma Health Care AuthorityPolicy N/A

Muscle Relaxant Prior Authorization Criteria

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This policy governs Oklahoma Health Care Authority prior authorization and tiered coverage criteria for skeletal muscle relaxants, including Tier-2 products, carisoprodol, tizanidine capsules, and extended-release cyclobenzaprine products.

Policy Summary

PayerOklahoma Health Care Authority

PolicyMuscle Relaxant Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of at least two Tier-1 muscle relaxants within the past 90 days before requesting Tier-2 approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Tier-1 failures required

90 daysCarisoprodol 350 mg limit

14 daysCarisoprodol 250 mg limit

3 monthsRepeat authorization window

1 year

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CurrentOklahoma Health Care AuthorityPolicy N/A

Muscle Relaxant Prior Authorization Criteria

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyMuscle Relaxant Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of at least two Tier-1 muscle relaxants within the past 90 days before requesting Tier-2 approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Tier-1 failures required

90 daysCarisoprodol 350 mg limit

14 daysCarisoprodol 250 mg limit

3 monthsRepeat authorization window

1 year

Chronic-condition authorization

Coverage Criteria

Initial Tier-2 Therapy

Tier-2 products are recommended for approval when ALL of the following are met:

ALL of the following

The member has failed at least two Tier-1 medications within the past 90 days.
Failure is defined as no beneficial response after at least two weeks of use during which the medication was titrated to the recommended dose.

Continuation Therapy

Repeat authorization is recommended when ALL of the following are met:

ALL of the following

There is documentation of a failed withdrawal attempt within the past three months.
A failed withdrawal attempt is defined as an increase in pain and debilitating symptoms when the medication was discontinued.

Authorization Duration

Authorization duration is based on the member's qualifying condition:

ONE of the following

The member does not have a qualifying chronic disease or chronic musculoskeletal diagnosis confirmed with diagnostic results.3 months
The member has a chronic disease such as multiple sclerosis, cerebral palsy, muscular dystrophy, paralysis, or another chronic musculoskeletal diagnosis confirmed with diagnostic results.1 year

Carisoprodol 350 mg Therapy

Carisoprodol 350 mg and carisoprodol 350 mg combination products are subject to the following cumulative and exception rules:

ALL of the following

The member's cumulative therapy does not exceed a 90-day therapy window within a 365-day period.90 therapy days per 365 days
ONE of the following
- After the cumulative therapy window, one additional approval is granted only to allow titration to or change to a Tier-1 muscle relaxant.1 additional month
  Further authorizations will not be granted after this transition period.
- A clinical exception applies for multiple sclerosis, cerebral palsy, muscular dystrophy, or paralysis.1 year

Carisoprodol 250 mg

Carisoprodol 250 mg is recommended for approval when ALL of the following are met:

ALL of the following

The member has acute musculoskeletal pain.14 days per 365-day period
Detailed documentation demonstrates the member's inability to use other skeletal muscle relaxants, including carisoprodol 350 mg.
Documentation provides the specific reason the member cannot be drowsy for even a short period of time.
The member does not have other sedating medications in the current claims history.

Conditions requiring chronic carisoprodol 250 mg use for acute musculoskeletal pain will not be approved.

After the cumulative 90-day therapy window, carisoprodol 350 mg or carisoprodol 350 mg combination products may receive only one additional month of authorization to allow titration or change to a Tier-1 muscle relaxant. Further authorization will not be granted unless a qualifying clinical exception applies; qualifying exceptions may be approved for one year for members with multiple sclerosis, cerebral palsy, muscular dystrophy, or paralysis.

Authorization Parameters

Tier-1 failure window

Minimum failed medicationsAt least 2 Tier-1 medications

Trial durationAt least 2 weeks of use for each medication

Trial requirementsEach medication must be titrated to the recommended dose and produce no beneficial response

Lookback windowWithin the past 90 days

Repeat authorization withdrawal window

Required eventA failed withdrawal attempt

Lookback windowWithin the past 3 months

Provider Requirements and Denial Risks

Prior Authorization

Tier-2 Prior Authorization

Tier-2 products require prior authorization after the member fails at least two Tier-1 skeletal muscle relaxants within the past 90 days. Each trial must last at least two weeks, include titration to the recommended dose, and produce no beneficial response.

Tier-1 options include cyclobenzaprine, baclofen, tizanidine, methocarbamol, chlorzoxazone, orphenadrine, and metaxalone.

Billing Rule

Carisoprodol 350 mg Duration Limit

Carisoprodol 350 mg and carisoprodol 350 mg combination products are limited to a cumulative 90 therapy-day window within 365 days. After that limit, only one additional month may be approved to permit titration or transition to a Tier-1 muscle relaxant; further authorization will not be granted.

Policy Background

This policy governs utilization of skeletal muscle relaxants, distinguishing lower-tier agents from Tier-2 products and formulation-specific therapies that require prior authorization. Tier-2 approval generally requires failure of at least two Tier-1 medications within the past 90 days, with each trial lasting at least two weeks, titrated to the recommended dose, and producing no beneficial response. The policy also applies formulation-specific sequencing, including tizanidine tablets before tizanidine capsules and consideration of generic cyclobenzaprine tablets before Amrix or Fexmid. Coverage distinguishes short-term treatment of acute musculoskeletal pain from treatment of qualifying chronic neurologic or musculoskeletal conditions.

Key Definitions

Failure of a Tier-1 medication

TermFailure of a Tier-1 medication

DefinitionNo beneficial response after at least two weeks of use

Dose requirementThe medication must have been titrated to the recommended dose

Failed withdrawal attempt

TermFailed withdrawal attempt

DefinitionAn increase in pain and debilitating symptoms when the medication was discontinued

Use in repeat authorizationDocumentation of a failed withdrawal attempt is required for repeat authorization

Initial Therapy Criteria

Initial Tier-2 Authorization

Initial Tier-2 authorization requires failure of Tier-1 therapy.

Tier-1 step requirement: The member failed at least two Tier-1 skeletal muscle relaxants within the past 90 days.At least 2 failed Tier-1 medications within 90 days

Each medication must have been used for at least two weeks, titrated to the recommended dose, and produced no beneficial response.

Tizanidine Capsules

Tizanidine capsules require use of the lower-cost tablet formulation first.

Tizanidine capsule authorization: Tizanidine tablets were tried before consideration of tizanidine capsules, and supporting information explains why the member cannot take the tablets.Prior tablet trial required

Continuation Criteria

Repeat Authorization

Repeat authorization requires documentation of a failed withdrawal attempt.

Continuation authorization: The member experienced increased pain and debilitating symptoms when the medication was discontinued within the prior three months.Failed withdrawal attempt within 3 months

Step Therapy Sequence

Step	Requirement	Details
1	Failure of at least two Tier-1 skeletal muscle relaxants before Tier-2 approval	Each medication must have been used within the past 90 days, for at least two weeks, titrated to the recommended dose, and produced no beneficial response.

Step	Requirement	Details
1	Trial of tizanidine tablets before tizanidine capsules	Tizanidine capsules may be considered only when supporting information explains why the member cannot take the tablets.

Step	Requirement	Details
1	Consider generically available cyclobenzaprine tablets before Amrix or Fexmid	Approval for Amrix or Fexmid requires clinical documentation that the member cannot take other generically available cyclobenzaprine tablet formulations.

Quantity and Duration Limits

Carisoprodol 350 mg quantity limit

ProductsCarisoprodol 350 mg and carisoprodol 350 mg combination products

Standard limit90 cumulative therapy days

Measurement periodPer 365 days

Carisoprodol 250 mg quantity limit

ProductCarisoprodol 250 mg

Approved indicationAcute musculoskeletal pain

Quantity limit14 days per 365-day period

Policy Summary

PayerOklahoma Health Care Authority

PolicyMuscle Relaxant Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of at least two Tier-1 muscle relaxants within the past 90 days before requesting Tier-2 approval.

SourceLink

On This Page

Clinical exceptions may be approved for the duration of one year.

Required documentationIncreased pain and debilitating symptoms when the medication was discontinued

Carisoprodol 350 mg cumulative therapy limit

ProductsCarisoprodol 350 mg and carisoprodol 350 mg combination products

Cumulative limit90 therapy days

Measurement periodPer 365 days

Carisoprodol 250 mg acute pain limit

ProductCarisoprodol 250 mg

IndicationAcute musculoskeletal pain

Approval limit14 days per 365-day period

Chronic useConditions requiring chronic use will not be approved

A one-year exception may apply for multiple sclerosis, cerebral palsy, muscular dystrophy, or paralysis.

Prior Authorization

Carisoprodol 250 mg Authorization

Carisoprodol 250 mg requires detailed clinical documentation showing why the member cannot use other skeletal muscle relaxants, including carisoprodol 350 mg, and why the member cannot be drowsy even for a short period.

The member must have acute musculoskeletal pain.
Approval is limited to 14 days per 365-day period.
Conditions requiring chronic use will not be approved.

Documentation Required

Formulation-Specific Authorization

Formulation-specific products require documentation supporting the requested formulation. Tizanidine capsules require a prior tablet trial and an explanation of why the member cannot take tablets; Amrix and Fexmid require documentation that the member cannot take other generically available cyclobenzaprine tablets.

Requested products include Zanaflex capsules, Amrix, and Fexmid.

Step Therapy

Tiered and Formulation Step Therapy

Tier-2 approval requires step therapy through appropriate Tier-1 skeletal muscle relaxants. For formulation-specific requests, lower-cost alternatives must also be tried when applicable, including tizanidine tablets before capsules and generic cyclobenzaprine tablets before extended-release products.

Document the medication, dose, duration, titration, response, and reason each required alternative was unsuccessful or cannot be used.

Documentation Required

Tier-1 Treatment History

Document at least two failed Tier-1 medication trials from the past 90 days. Each trial must include at least two weeks of use at the recommended dose, with no beneficial response.

Record the medication name, treatment dates or timing, dose and titration, and clinical response.

Unsupported block type: documentation

Documentation Required

Carisoprodol 250 mg Exception Documentation

For a carisoprodol 250 mg exception, provide a specific clinical rationale explaining why the member cannot use other skeletal muscle relaxants, including carisoprodol 350 mg, and why even brief drowsiness is unacceptable.

Support the exception with member-specific clinical facts rather than a general statement of preference.

Documentation Required

Sedating Medication Review

Before requesting carisoprodol 250 mg, review current claims history and verify that the member is not taking other sedating medications.

The absence of other sedating medications must be supported by the current claims history.

Documentation Required

Tizanidine Formulation Documentation

For tizanidine capsules, document why the member cannot take tizanidine tablets after the required tablet trial or explain the clinically supported inability to use tablets.

Capsule approval is contingent on supporting information specific to the member's inability to take tablets.

Documentation Required

Generic Cyclobenzaprine Intolerance Documentation

For Amrix or Fexmid, document the member's inability to take other generically available cyclobenzaprine tablets.

The rationale must address inability to use generic cyclobenzaprine tablets, not merely a preference for extended-release therapy.

Denial Risk

Insufficient Tier-1 Treatment Failure

Tier-2 authorization is not recommended when the member has not failed at least two Tier-1 medications within the past 90 days under the required trial conditions.

Each trial must include at least two weeks of treatment and titration to the recommended dose.
No beneficial response must be documented.

Denial Risk

No Failed Withdrawal Attempt

Repeat authorization is not recommended when there is no documented failed withdrawal attempt within the past three months.

The record must show increased pain and debilitating symptoms after discontinuation.

Denial Risk

Carisoprodol Duration Exceeded

Carisoprodol 350 mg and combination products will not receive further authorization after the cumulative 90-day window and the additional one-month titration or transition period, unless a specified chronic-disease exception applies.

The additional month is for titration or change to a Tier-1 muscle relaxant.
Qualifying exceptions include multiple sclerosis, cerebral palsy, muscular dystrophy, or paralysis, with approval for one year.

Denial Risk

Chronic Use for Acute Pain

Carisoprodol 250 mg is limited to acute musculoskeletal pain and 14 days per 365 days. Requests for chronic use will not be approved.

Document the acute diagnosis and the requested treatment period.

Denial Risk

Capsule Request Without Tablet Trial

Tizanidine capsules will not be approved when tizanidine tablets have not been tried, unless supporting information establishes why the member cannot take the tablets.

Document the tablet trial and outcome, or the member-specific contraindication or inability to use tablets.

Denial Risk

Extended-Release Cyclobenzaprine Lacks Justification

Amrix or Fexmid will not be approved without clinical documentation explaining why the member cannot take other generically available cyclobenzaprine tablets.

A request based only on preference for an extended-release formulation is insufficient.

Tier-2 product

TermTier-2 product

Product typeA skeletal muscle relaxant designated for prior authorization

Typical requirementGenerally requires failure of Tier-1 therapy

Amrix and Fexmid

Amrix and Fexmid require documentation regarding generic alternatives.

Extended-release cyclobenzaprine authorization: Clinical documentation shows the member is unable to take other generically available forms of cyclobenzaprine tablets.Generic cyclobenzaprine tablet alternative considered

Chronic useConditions requiring chronic use will not be approved

Additional carisoprodol 350 mg transition period

ProductsCarisoprodol 350 mg and carisoprodol 350 mg combination products

Additional approvalOne additional month

Permitted purposeTo allow titration or change to a Tier-1 muscle relaxant

After the transition periodFurther authorizations will not be granted, except for specified clinical exceptions